Insurance Information

Insurance Information

Yes, insurance applies to meNo, insurance does not apply to me

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

Are you being treated for any medical condition at the present or any time within the past year?

Are you being treated for any medical condition at the present or any time within the past year?

YesNoNot Sure/Maybe

When was your last medical check-up?

Has there been any change in your general health in the past year?

Has there been any change in your general health in the past year?

YesNoNot Sure/Maybe

Are you taking any prescription, non-prescription medications, or herbal supplements?

Are you taking any prescription, non-prescription medications, or herbal supplements?

YesNoNot Sure/Maybe

Do you have any allergies?

Do you have any allergies?

YesNoNot Sure/Maybe

Have you ever had a peculiar or adverse reaction to any medicines or injections?

Have you ever had a peculiar or adverse reaction to any medicines or injections?

YesNoNot Sure/Maybe

Do you have or ever had asthma?

Do you have or ever had asthma?

YesNoNot Sure/Maybe

Do you have or ever had any heart or blood pressure problems?

Do you have or ever had any heart or blood pressure problems?

YesNoNot Sure/Maybe

Have you ever/do you have an artificial heart valve, infection of the heart (i.e.infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

Have you ever/do you have an artificial heart valve, infection of the heart (i.e.infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

YesNoNot Sure/Maybe

Do you have a prosthetic or artificial joint?

Do you have a prosthetic or artificial joint?

YesNoNot Sure/Maybe

Do you have any conditions which may affect your immune system? (i.e. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy)

Do you have any conditions which may affect your immune system? (i.e. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy)

YesNoNot Sure/Maybe

Have you ever had hepatitis, jaundice, or liver disease?

Have you ever had hepatitis, jaundice, or liver disease?

YesNoNot Sure/Maybe

Do you have a bleeding problem or bleeding disorder?

Do you have a bleeding problem or bleeding disorder?

YesNoNot Sure/Maybe

Have you ever been hospitalized for any illnesses or operations?

Have you ever been hospitalized for any illnesses or operations?

YesNoNot Sure/Maybe

Do you have, or have ever had any of the following? Please check.

Do you have, or have ever had any of the following? Please check.

YesNoNot Sure/Maybe

Are there any conditions/diseases not listed that you have or have had?

Are there any conditions/diseases not listed that you have or have had?

YesNoNot Sure/Maybe

Are there any diseases/medical problems that run in your family (eg-diabetes, cancer, heart disease)?

Are there any diseases/medical problems that run in your family (eg-diabetes, cancer, heart disease)?